mm disorders and tx pt one

Question 1

Musculoskeletal Disorders

which are centrally maintained

Answer 1

1. Myofascial Pain Syndrome (MFPS)- Centrally Maintained
   Pain
2. Myalgia
3. Fibromyalgia- Centrally Maintained Pain
4. Spasm
5. Myositis

Question 2

mc Musculoskeletal Disorder

Answer 2

myalgia

Question 3

which Musculoskeletal Disorder is tx by rheumatologist

Answer 3

fibromyalgia

Question 4

main tx modality for musculoskeltal dx

Answer 4

PT

Question 5

spasms can follow?

Answer 5

trauma/bruxism

Question 6

myostitis can follow

Answer 6

trauma/infection

Question 7

Mechanisms that produce Pain for Masticatory skeletal muscles

Answer 7

Question 8

Myofascial Pain Syndrome characterized by?

Answer 8

Characterized by the presence of Trigger Points (TPs) in any voluntary muscle which cause referred pain and referred tenderness and may be active or latent up palpation/function.

Question 9

TPs evoke?

Answer 9

TPs evoke referred pain which usually originates from a distant site
rather than the site of the pain complaint.

Question 10

ACTIVE TPs

Answer 10

ACTIVE TPs: are painful to palpation or spontaneously produce local pain OR refer pain and autonomic symptoms (i.e. erythema) to remote areas in reproducible patterns characteristic of each muscle

Question 11

LATENT TPs

could occur with?

Answer 11

LATENT TPs: exhibit local tenderness but do not currently cause
spontaneous clinical pain or symptoms.

could occur with previous trauma that was not adressed

Question 12

Myofascial Trigger Point
 DEFINITION:
 pain sensation described?

Answer 12

 An irritable locus within a taut band of skeletal muscle or fascia which when stimulated elicits referred pain & tenderness (“secondary hyperalgesia- increased sensitivity to normally painful stimuli outside & surrounding a zone of primary hyperalgesia”). (1)

 Referred pain from myofascial trigger points is dull and aching, usually deep, and can range from discomfort to incapacitating pain.

1/2 nn interconnect which can allow pain to cross CN distributions (5/11

Question 13

Muscle Palpation Examination
 Remember that the pain location ?
 Palpate which muscles with mouth open

Answer 13

Muscle Palpation Examination
 Remember that the pain location MAY not be the source of pain
 Palpate the Masseter and Temporalis muscles with mouth open

Question 14

Myofascial Pain Syndrome (MFPS)
 May be found in what mm?
 mediation?

Answer 14

 May be found in any voluntary muscle
 Is a Centrally Mediated Pain. Fields (4) described a means where the CNS may switch on Nociception by stimulating the “on” cells which causes activation of the Trigeminal Nucleus nociceptors

Question 15

Myofascial Pain Syndrome, chronic?

Answer 15

Is chronic, continuous muscle pain (myalgia) that is aggravated by function and refers pain beyond the boundary of the masticatory muscle being palpated

Question 16

Nociception:

Answer 16

Nociception: “stimulation of specialized nerve endings designed to transmit
information to the central nervous system concerning potential or actual tissue
damage

Question 17

Nociceptor:

Answer 17

Nociceptor: “a specialized nerve ending that senses painful or harmful sensations”
(i.e. a primary afferent nerve)

Question 18

Myofascial Pain diagnosis difficulty, why?

scm refferal patterns

Answer 18

Myofascial Pain
 The most elusive and difficult to diagnose since it refers
pain to other locations in the mouth and in the face and
head & does Not always follow Cranial Nerve Distributions-
(CN XI with active SCM trigger point refers to CN V in face
and head)

Question 19

Myofascial Pain
 Diagnostic Criteria: (must be present):
 pain type? aggrevated by?

 tps?

 > 50% pain reduction occurs with?

Answer 19

 Regional dull, aching pain aggravated by mandibular function when muscles of mastication are involved.

 Trigger points have a characteristic pattern of pain referral & alters the pain complaint on palpation or spontaneously.

 > 50% pain reduction occurs with vapocoolant spray or local anesthetic injection (trigger point injection) using 1% Procaine without vasoconstrictor.

Question 20

Myofascial Pain
 May be accompanied by:
 Muscle?
 Sensation of?
 Ear? teeth? HA?
 ROM?
 pain in referal region

Answer 20

 Muscle stiffness
 Sensation of acute malocclusion not verified clinically.
 Ear Symptoms, tinnitus, vertigo, toothache, tension-type headache.
 Decreased mouth opening (if masticatory muscles involved).
 Hyperalgesia in region of referred pain.

Question 21

Pathophysiology of Masticatory Myofascial Pain
 understood?
1. thresholds?
2. what may cause increased nociception which causes pain sensitivity?
3. CNS?

Answer 21

 Not fully understood
1. Suspect lower pain thresholds in these individuals
2. Estrogen and nerve growth factor (NGF) may cause increased nociception which causes pain sensitivity
3. Hyperexcitability in CNS & upregulation of nociceptive processing (decreased inhibition of pain)

Question 22

TMJ & Ear Pain:
 Referred by which mm:

Answer 22

 MASSETER (deep)
 LATERAL PTERYGOID
 MEDIAL PTERYGOID
 STERNOCLEIDOMASTOID (clavicular

Question 23

Toothache:
 Referred by which mm:

Answer 23

 TEMPORALIS
 MASSETER (superficial)
 DIGASTRIC (anterior)

Question 24

masetter referal patterns

Answer 24

Question 25

temporalis refferal patterns

Answer 25

Question 26

digastric and medial pterygoid refferal patterns

Answer 26

Question 27

Lateral Pterygoid Referral pattern

Answer 27

Question 28

SCM refferal

Answer 28

Question 29

Myofascial Pain  May be?  Avoid what txs?

Answer 29

Myofascial Pain  May be transient and self-limiting, resolving without serious long-term effects.  Avoid irreversible treatments (i.e. occlusal adjustments)

Question 30

Myalgia  Diagnostic Criteria: (must be present) 1. Muscle pain reported by patient in ? 2. Pain is aggravated by? 3. Muscle palpation exam causes?

Answer 30

1. Muscle pain reported by patient in the jaw, temple, ear or pre-auricular area in the last 30 days 2. Pain is aggravated by jaw movement or parafunction (i.e. bruxism) 3. Muscle palpation exam causes report of localized muscle pain at palpation site

Question 31

what may be present with myalgia

Answer 31

Limited range of mouth opening MAY be present

Question 32

# myalgia is secondary to?

Answer 32

 Ischemia  Bruxism  Fatigue  Metabolic alterations  Delayed onset muscle soreness from overuse  Protective splinting

Question 33

Myositis  Diagnostic Criteria must be present: 1. pain following? 2. tissue app?

Answer 33

1. Local muscle pain following injury (non-infective) or infection (infective) 2. Edema, erythema, &/or increased temperature over the muscle

Question 34

myostitis may be present: 1. Serologic tests may reveal? 2. tender? 3. Increased pain with? 4. ROM

Answer 34

1. Serologic tests may reveal elevated enzyme levels (i.e. creatine kinase), markers of inflammation & the presence of an autoimmune disease. 2. Diffuse tenderness over the entire muscle. 3. Increased pain with jaw use if masticatory muscles involved. 4. Limited range of motion of unassisted mandibular movements secondary to pain

Question 35

Myospasm  Diagnostic criteria Must be present: 1. pain with? 2. ROM? 3. contractions? 4. EMG will Confirm?

Answer 35

1. Acute onset of pain at rest & with function. 2. Immediate report of limited range of jaw motion <40mm for vertical opening 3. Continuous involuntary muscle contraction 4. EMG will Confirm elevated electromyographic activity compared to the contralateral unaffected muscle.

Question 36

myospasm may be present:

Answer 36

Acute Malocclusion

Question 37

Myospasm  Also known as?  occurence? typical cause?  Difficult to differentiate between? 1st line tx

Answer 37

Myospasm  Also known as “trismus” or “cramp”.  Occurs relatively infrequently in orofacial pain population & typically is caused by trauma.  Difficult to differentiate between disc displacement without reduction clinically when limited unassisted vertical range of mouth opening is <40mm. | tx with PT

Question 38

Contracture  defined?  pain?  History of ?

Answer 38

Contracture  Shortening of a muscle due to fibrosis of tendons, ligaments, or muscle fibers  Usually not painful unless muscle is overextended  History of radiation therapy, trauma, or infection is often present

Question 39

Contracture Diagnostic Criteria MUST be present: 1.ROM?

Answer 39

1. Progressive loss of range of motion with unassisted and assisted opening < 40mm causing a “hard end feel”

Question 40

Fibromyalgia Pathophysiology:  understood? beleieved to involve?  little evidence of ?  may involve dysfunction of?

Answer 40

 is poorly understood but believed to involve a central sensitivity syndrome  little evidence of peripheral tissue abnormalities  may involve dysfunction of autonomic nervous system

Question 41

Associated Co-morbid Medical disorders of fibromyalgia

Answer 41

 TMD (10% of population)  Inflammatory & neuroendocrine disorders  IBS, functional chest pain from esophageal origin  Chronic pelvic pain  Headaches especially Migraines

Question 42

FIBROMYALGIA  Diagnostic Criteria MUST be present: 1. Tenderness on palpation ? 2. Presence of? 3. Pain is?

Answer 42

1. Tenderness on palpation of at least 11 of 18 specified sites 2. Presence of wide-spread pain with concurrent masticatory muscle pain 3. Pain is bilateral and present above & below the waist

Question 43

Fibromyalgia psych associations

Answer 43

May be associated with sleep deprivation & depression

Question 44

FM tx

Answer 44

Refer to a rheumatologist for evaluation & treatment

Question 45

s/s of FM | dental related?

Answer 45

Tingling, numbness, tightness, stiffness & swelling may affect the jaw. Dizziness is common. Toothache & gingival pain occur commonly in fibromyalgia patients.

Question 46

Fibromyalgia Medications Effective:

Answer 46

 Lyrica (pregabalin)  Antidepressants (i.e. amitriptyline)  Savelle (SNRI)

Question 47

Fibromyalgia Medications Minimally Effective:

Answer 47

 NSAIDs  Opioids  Benzodiazepines

Question 48

Fibromyalgia Conservative Treatment 1. Sleep? 2. therapy? 3. activity?

Answer 48

1. Sleep hygiene- keep bedtime & awakening time the same each day; only sleep while in bed- no TV or computers; rule out obstructive sleep apnea 2. Cognitive behavioral therapy to cope with pain 3. Light impact aerobic activity (i.e. swimming, beginner’s aerobic class) 4. Strength training with light weights

Question 49

MOVEMENT DISORDERS: OROFACIAL DYSKINESIA  INVOLVES?  MAY involve what?  MAY cause injury to?  More common with?  Patient must provide a history of?  Cranial nerve examination is positive for?

Answer 49

 INVOLVES INVOLUNTARY, CHOREATIC MOVEMENTS  MAY involve the face, lips, and/or the jaw.  MAY cause traumatic injury to the tongue or oral mucosa  More common with advancing age, use of neuroleptic medications and/or traumatic brain injury, psychiatric or certain neurologic disorders  Patient must provide a history of dyskinesia involving the orofacial region, history and examination is positive for myalgia and arthralgia that worsens with episodes of dyskinesia  Cranial nerve examination is positive for sensory &/or motor nerve conduction deficit (i.e. Trigeminal nerve)

Question 50

MOVEMENT DISORDERS: OROFACIAL DYSTONIA  INVOLVES ?  MAY involve what tissues?  pain? impacts?  Traumatic injury to?  More common with certain?  Patient must provide a history of ?  Cranial nerve examination is positive for?  Intramuscular EMG?

Answer 50

 INVOLVES INVOLUNTARY, EXCESSIVE SUSTAINED MUSCLE CONTRACTIONS  MAY involve the face, lips, tongue and/or the jaw disappearing during SLEEP.  Painful & can make opening/closing of mouth difficult; can impair speech, swallowing & chewing  Traumatic injury to the brain/head/neck can trigger transient or permanent dystonia involving the MASTICATORY MUSCLES  More common with certain neurologic disorders (i.e. Parkinson’s Disease), or adverse reaction to medications especially neuroleptic medications  Patient must provide a history of dystonia involving the orofacial region, history and examination is positive for myalgia and arthralgia that worsens with episodes of dystonia  Cranial nerve examination is positive for sensory &/or motor nerve conduction deficit (i.e. Trigeminal nerve, Facial nerve)  Intramuscular EMG confirms the dystonia diagnosis

Question 51

Treatment of Masticatory Muscle Pain  Goals of Treatment: 1. Decrease? 2. Increase? 3. Resumption of? 4. Onabotulinum A injections for?

Answer 51

1. Decrease pain 2. Increase range of motion 3. Resumption of normal daily activities (i.e. talking, eating a normal diet) 4. Onabotulinum A injections for Oromandibular Dyskenesia and Dystonias